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Tribalism Kills; The Journey Towards Genuine Integration

David Attwood is a GP with a Specialist Interest in Older People. He is a Committee Member of BGS’s GeriGP Group. He tweets @DavidAttwood12

“You have twenty-one children?!” I asked incredulously. The Fanta that was halfway to my mouth almost left my hand to land on my khaki coloured trousers.

“Yes, twenty-one.” William replied, between mouthfuls of Nile perch. After a pause to finish chewing he casually added, “and four wives.”

The Fanta fell out of my mouth to land on my trousers.

“Do they all get on well?”

He screwed his face and smiled mischievously “No! They are constantly arguing!!”

I had to laugh.

Then another cheeky thought dawned. “and how is Christmas in your house?” The South Sudanese are mostly Christians.

It was his turn to laugh “I make sure I work that day!”

I had known William, the Hospital Administrator, for some time and we were firm friends. I had been going to Juba Teaching Hospital (JTH), South Sudan, for the best part of a decade. The people were warm and kind and I had made good friends with many of the staff; the result of sharing good conversations, good times, and numerous hardships.

I had finished my Core Medical Training and taken a natural career break with my wife to work in South Sudan and defer my transition to medical registrar. However, on my first day, two things became immediately apparent. Firstly, consultants in South Sudan need only five years of postgraduate training and a higher qualification. Secondly, I had five years of postgraduate training and my MRCP. This striking similarity was duly noted by the Medical Director on my induction who suggested I work as a consultant in the Emergency Medical Ward. The strength and tone of his response hinted that saying “no” was not an option. So much for deferring my med reg years.

Fast forward three and a half months.

We were coming to the end of our attachment in JTH and here I was with William, eating lunch. “Are you ready?” he asked.

I furrowed my eyebrows and looked up, my gaze meeting his. “As ready as we will ever be. The ward is empty, our HDU bed has been cleared, and we have raided every store room in JTH for bandages, cannulas, fluids, and antibiotics. We are as ready as we can be for the casualties. How about you?”

“We are ready. I have seen to it.” William was a man of few words and many matter-of-fact comments. He was an absolute giant of a man that loved South Sudan, loved the hospital, and was amazing at getting things done.

A major incident had been declared at JTH. Two tribes, the Nuer and Murle had clashed and hundreds had been killed and wounded. Lorries were inbound to JTH laden with casualties from both sides, including women and children. William had banged some heads together in the Ministry of Health and JTH was restocked with diesel, cannulas, fluids, and operating materials. The generators supplying the lights to the operation rooms hummed. Everyone in JTH was poised. All the staff on the EMU were staying late. Being medics, we had no experience of managing trauma cases, but we had all agreed to work alongside the surgeons triaging cases, and following their management plans.

“How did all this happen?” I asked.

Another mouthful of Nile perch. “Cows.” He swallowed, washed the food down with some lemonade and then elaborated. It transpired that the cow is a form of currency in rural South Sudan and in these areas, tribes have herds of hundreds of cows.

Now there are two ways to increase your herd. Firstly you can breed, which takes time. A second and much faster way is to steal them from another tribe.

“The way they do this is very, very clever.” continued William.

He went on to tell me about the intricate process of cattle rustling. The planning would sometimes take months. Wells and provisions depots were dug at key intervals from one tribe to the next. Following the conflict, which had evolved from spears into the much more efficient killing machine that is the Kalashnikov, the raiders would return via their intricate well system, poisoning each well as they left so a counter attack would be left short of water and supplies.

That long day and longer night took place around New Years Eve, 2011. Seven years on, the memories remain. Tribalism kills.

As I reflect on my time in South Sudan, it is hard not to draw parallels with our NHS. In our healthcare system, we all enjoy being in a tribe, whether it be the “doctor tribe”, the “management tribe” etc. There are often “tribes within tribes,” for example the “geriatrician tribe” or the “GP tribe.” These tribes have their own forts and their own agendas, driven by cash cows. Conflict often erupts between tribes because of cash cows. This melting pot of activity is fertile ground for the two biggest silent killers in our healthcare system; demotivation and apathy.

Tribalism does not work. We exist in a world where the cost of care for older people living with frailty, multi-morbidity, and dementia is threatening the very existence of our NHS. There is a wealth of research demonstrating that single activity interventions performed by one tribe hardly ever result in demonstrable health benefit to this patient cohort or economic benefit to the system.

However, there is robust evidence that Comprehensive Geriatric Assessment (CGA), a process that is shared/inputted into by multiple tribes, can improve the health outcomes for older people.

This suggests two things. Firstly, we can achieve more working together than in our siloed tribes. Secondly, if working together we can achieve CGA, imagine what we might be able to accomplish if we adopted joined up working in other aspects of an older person’s unplanned and proactive care needs.

In a future blog I will discuss how we can overcome tribalism, elaborating on the concept of the “tribal perspective.” Each profession perceives life through the eyes of history; our thoughts, our actions, EVERYTHING, is inextricably linked with the limitations of this perspective.

However, that tale lies in the future.

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